edCurrent… (and how herbs and other natural remedies such as Cannabidiol or ‘CBD’ could possibly play a role in helping those affected)

Introduction to ADHD

Attention deficit hyperactivity disorder, more commonly known as ADHD, is one of the most prevalent neuropsychiatric disorders of childhood and adolescence. It is estimated that ADHD affects roughly 10% of children and adolescents in the United States.1 This particular disorder typically manifests itself during early childhood with symptoms of hyperactivity, impulsivity, and inattention. These symptoms have the ability to affect cognitive, academic, behavioral, emotional, and social functioning. In fact, ADHD is known to be linked with a high rate of comorbid psychiatric complications such as oppositional defiant disorder (ODD), mood and anxiety disorders, conduct disorder, and substance use disorders.

Although the symptoms of ADHD begin in childhood, they can continue through adulthood. Epidemiology derived data revealed that 4% to 5% of college aged students and adults suffer from ADHD. In most cases, the hyperactivity aspect of the disorder tends to improve as an individual grows older. However, problems with inattention, disorganization, and poor impulse control often continue into adulthood. Across the lifespan, the social and societal costs of ADHD are extensive if left untreated and presents the risk of academic and occupational underachievement, delinquency, motor vehicle safety, and difficulties with obtaining and maintaining personal relationships. This makes it extremely vital for individuals suffering from the disorder to seek appropriate care and treatment. But, how does one know they have ADHD? How is it diagnosed and treated? The purpose of this article is to inform about the clinical presentation and manifestations of ADHD, the diagnosis, and various treatment options including stimulants and non-stimulant medications that are currently available for those affected. Attention is also given to herbal medicines and natural remedies such as cannabidiol (CBD) for the role that they could play in managing certain conditions associated with ADHD.

 

Clinical Presentation of ADHD

People suffering from ADHD frequently show an ongoing pattern of three specific types of symptoms; difficulty paying attention (inattention), being overactive (hyperactivity), or acting without thinking (impulsivity). Often, individuals have a combination of these symptoms which disrupt normal functioning and development. The following describes the symptoms and signs specific to each of the three categories related to ADHD:

Inattentive

  • Short attention span for age
  • Difficulty attending to details
  • Difficulty listening to others
  • Forgetfulness
  • Easily distracted
  • Poor study skills for age
  • Poor organizational skills for age

Hyperactive

  • Talks excessively
  • Loses or forgets things repeatedly and often
  • Has difficulty engaging in quiet activities
  • Has difficulty remaining in his/her seat, even when expected
  • Inability to stay on task without full completion
  • Seems to be in constant motion; includes running or climbing with no apparent goal except motion
  • Fidgets with hands or squirms excessively when seated

Impulsivity

  • Tends to blurt out answers instead of waiting to be called upon
  • Has difficulty waiting their turn in school or social games
  • Takes frequent risks; often without thinking before acting
  • Often interrupts others

Although the clinical presentation of ADHD can be similar in children/adolescents and adults, the disorder’s effects can differ between the two age groups. Inattention symptoms in adults are primarily related to decreased focus during specific tasks, especially for long periods. Adults suffering from inattention symptoms have difficulties with organizing activities, prioritizing tasks, following through and completing tasks, forgetfulness, and time management. Inattention symptoms in adults also have the ability to negatively impact driving capability as they can lead to driving errors, traffic tickets, and speeding. Impulsivity in adult ADHD is characterized by excessive involvement in activities or speech.

Compared to childhood ADHD, adults with ADHD experiencing impulsivity can often result in more serious consequences. This can include premature termination in personal relationships or quitting a job with no back up plan. Lastly, hyperactivity symptoms tend to differ in adults compared to children and adolescents. Rather than being overly hyperactive, such as excessive running or climbing, adults with ADHD often report feelings of excessive restlessness and constant fidgeting when seated. The reason why the effects of ADHD can differ based on age is still not well understood. One proposed theory is that as an individual matures, they are more likely to understand what is going on and can maintain the disorder better than immature individuals. Overall, ADHD can be a lifelong condition that may present less noticeably or differently in adults when compared to children/adolescents, though it is just as important to identify.2,3,4

Types of ADHD

As mentioned previously, ADHD typically involves the three symptom categories of inattention, hyperactivity, and impulsivity. While it is possible for an individual with ADHD to have symptoms related to all of the categories, some individuals only experience symptoms related to one of the symptom categories. Therefore, the disorder can be further defined in an individual as the inattentive type, the hyperactive/impulsive type, and the combinational type.

With the inattentive type, these individuals usually experience more symptoms of decreased attention span and a lack of focus than those of impulsivity and hyperactivity. One with this type of ADHD still may struggle with impulse control or hyperactivity at times, but these are not the main symptoms that effect the individual.

With the predominately hyperactive-impulsive type, individuals have more difficulties with spontaneous/unrepressed behavior and the “on the go” attitude rather than a lack of attention. The hyperactive-impulsive type still can display signs of inattention but is not as marked as the other symptoms.

Lastly, if an individual has the combinational type of ADHD, it means that their symptoms do not exclusively fall within either of the two types mentioned earlier. Instead, a combination of symptoms from both of the categories are exhibited and prevalent. One thing to keep in mind is that everyone, with or without ADHD, experiences some level of inattentive or hyperactive-impulsive behavior. However, these symptoms are at increased severity in people with ADHD. The behavior occurs more often and interferes with the individual to the point that it is dramatically affecting their quality of life. Correctly identifying the specific type of ADHD is directly related to how the disorder is diagnosed, which will be discussed later on.2,3,4

What Causes ADHD?

The definite cause of why ADHD occurs in individuals is still uncertain. Current research suggests that ADHD may be caused by specific interactions between an individual’s genetic composition and environmental factors. Similar with other disorders, a number of factors have the potential to increase the risk of developing ADHD. These factors include cigarette smoking/alcohol use/drug use during pregnancy, low birth weight, exposure to environmental toxins (such as high levels of lead at a young age), and brain injuries. Interestingly, ADHD is more common in boys than girls with a male to female ratio of 4:1 for the predominantly hyperactive-impulsive type and 2:1 for the predominantly inattentive type.5 The National Institute of Mental Health explains that the most children have the combinational type of ADHD with the most common symptom being hyperactivity. More studies need to be conducted in order to help identify what puts individuals at the greatest risk for developing ADHD.2

ADHD Pathophysiology

The pathophysiology of ADHD is exceptionally complex and still not well understood. Current research has conceptualized ADHD as a disorder affecting frontal circuitry of the brain due to associated deficits in executional cognitive functioning. Structural imaging studies have demonstrated noticeable abnormalities in children and adults with ADHD. These imaging studies reported that brains belonging to adults suffering from ADHD had a smaller total cerebrum, cerebellum, as well as the four cerebral lobes, none of which changed over time. It was also shown that adults with ADHD have a smaller anterior cingulate cortex (ACC) and dorsolateral prefrontal cortex (DLPFC).

The DLPFC is directly involved with working memory that involves the ability to retain information while processing new information simultaneously. The ACC is known as a significant region within the brain involved with the ability to focus on one task and choose between options being presented to an individual. Differences revealed from imaging studies are thought to account for the deficits in goal-directed and on task behavior in ADHD. One study that used functional magnetic resonance imaging (fMRI) to measure brain activity found that both youth and adults with ADHD had reduced activity in the frontostriatal regions of the brain. These regions are directly responsible for inhibitory control and maintaining attention. Other studies have also shown evidence in deficits of the meso-cortical brain network and reward processing in individuals suffering from ADHD. These abnormalities are associated with dysfunctions in the mesolimbic dopaminergic system.

Finally, research suggests that the Default-Mode-Network (DMN), which is usually prominent at rest, may be irregular in people with ADHD. This disrupted DMN activity within the central nervous system may interfere with activity in neuronal networks engaged in task processing, leading to difficulties in state regulation and periodic attention lapses. Although much research has been conducted in the field of ADHD pathophysiology, more studies will need to be completed in order to fully understand this specific condition.2,4,6

Diagnoses of ADHD

In order to accurately diagnose ADHD, healthcare providers use the guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth edition (DSM-5). This standard helps to ensure that people are correctly diagnosed and treated for ADHD. As mentioned before, people with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Below are the specific criteria to identify ADHD in children, adolescents, and adults.

Inattention: six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months and they are inappropriate for the person’s development level:

  • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities
  • Often has trouble holding attention on tasks or play activities
  • Often does not seem to listen when spoken to directly
  • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
  • Often has trouble organizing tasks and activities
  • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time
  • Often loses things necessary for tasks and activities
  • Is often easily distracted
  • Is often forgetful in daily activities

Hyperactivity and impulsivity: six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s development level:

  • Often fidgets with or taps hands or feet, or squirms in seat
  • Often leaves seat in situations when remaining seated is expected
  • Often runs about or climbs in situations where it is not appropriate (adolescents and adults may be limited to feeling restless)
  • Often unable to play or take part in leisure activities quietly
  • Is often “on the go” acting as if driven by a motor
  • Often talks excessively
  • Often blurts out an answer before a question has been completed
  • Often has trouble waiting their turn
  • Often interrupts or intrudes on others

In addition to the above criteria, the following conditions must be met in order to diagnose a person with ADHD:

  • Several inattentive or hyperactivity-impulsivity symptoms were present before the age of 12 years
  • Several symptoms are present in two or more settings (such as home, school, work, with friends or relatives, ect.)
  • There is clear evidence that the symptoms interfere with, or reduce the quality of social, school, or work functioning
  • The symptoms are not better explained by another mental disorder (such as anxiety, depression, mood disorder, dissociative disorder, or personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.

Based on the above criteria, a healthcare provider can narrow an individual’s ADHD to a specific type. For the combinational type, enough symptoms of both criteria have to be present for the past six months. For the predominately inattentive type, enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months. And for the predominately hyperactive-impulsive type, enough symptoms of hyperactivity-impulsivity, but not inattention, were present for the past six months.7

Treatment

Although ADHD is not a curable condition, there are treatments that may help reduce symptoms and improve functioning. The first line treatment for ADHD is stimulants. While it may sound unusual to treat ADHD with a medication that is considered a stimulant, these medications are extremely effective. In fact, roughly 85% of individuals with ADHD respond positively with the addition of a stimulant. This medication works by increasing a specific chemical in the brain, dopamine, which plays an essential role in thinking and attention. Non-stimulant medications can also be used in the treatment of ADHD. These medications have a longer onset of action than stimulants, but can also improve focus, attention, and impulsivity in persons with ADHD. Non-stimulants are commonly used if a person had bothersome side effects from a stimulant, if a stimulant was not effective, or in combination with a stimulant to increase effectiveness and symptom control.

Some examples of non-stimulant medications include atomoxetine and guanfacine. Atomoxetine is effective in treating ADHD as it increases levels of norepinephrine within the brain, which in turn increases attention span and reduces impulsive behavior and hyperactivity. Guanfacine helps relieve ADHD symptoms by affecting the central noradrenergic system which leads to strengthened working memory, reducing distraction, and improving attention and impulse control. Another type of non-stimulant that is used in persons with ADHD is antidepressants. Although antidepressants are not approved by the FDA specifically for the treatment of ADHD, these medications are sometimes used in adults with ADHD. Tricyclic antidepressants are commonly the antidepressant of choice because they act to increase the brain chemicals of dopamine and norepinephrine, just like stimulants and atomoxetine. However, tricyclic antidepressants come with a hefty load of side effects that individuals need to be aware about before utilizing. Besides medications, ADHD affected individuals need to be educated about the disorder and undertake cognitive behavioral therapy in order to improve outcomes and better maintain their condition.2,4

Cannabidiol as a Possible Alternative Treatment Option

An up and coming alternative treatment for people with ADHD is the use of cannabidiol, or CBD. This product has been shown to improve outcomes in epileptic patients, schizophrenic patients, and individuals suffering from anxiety. CBD is a compound found in the cannabis plant but is completely different from tetrahydrocannabinol (THC), another compound also found in cannabis that creates euphoria and delivers the “high” experience. Unlike THC, CBD does not have any psychoactive component and is unable to create the euphoria experience. So how can this natural remedy be helpful in ADHD? Research has demonstrated that CBD has a “calming” effect on the body (both centrally and peripherally). This in turn could help relieve the impulsive and hyperactive symptoms that ADHD individuals experience. The compound works to induce its calming effects by playing an active role in the serotonin system, reuptake inhibition of certain neurotransmitters, and other unknown activity in the limbic and paralimbic brain areas.

Currently there is a lack of detailed scientific analysis specific to attention deficit hyperactivity disorder natural remedies. As such more research will be needed in order to validate CBD’s use in ADHD treatments and to recommend the product clinically. However, individuals who have failed multiple lines of therapy for ADHD may be inclined to try CBD (as well as other natural treatments and herbal remedies) in order to relieve symptoms. If this is the case, it is vital that individuals are only using lab tested broad-spectrum or isolate CBD products with no THC. Full-spectrum CBD as well as other untested CBD products currently available will contain trace amounts of THC, which is not appropriate for children and adolescents. Overall, one should discuss any potential administration of CBD with one’s healthcare provider to ascertain what the best treatment specific to their ADHD might be and to see if CBD could be a potential alternative therapy option.

 

References

  1. Xu G, Strathearn L, Liu B, Yang B, Bao W. Twenty-Year Trends in Diagnosed Attention-Deficit/Hyperactivity Disorder Among US Children and Adolescents, 1997-2016. JAMA Netw Open. 2018;1(4):e181471. Published 2018 Aug 3. doi:10.1001/jamanetworkopen.2018.1471
  2. Wilens TE, Spencer TJ. Understanding attention-deficit/hyperactivity disorder from childhood to adulthood. Postgrad Med. 2010;122(5):97-109. doi:10.3810/pgm.2010.09.2206
  3. Attention-Deficit / Hyperactivity Disorder (ADHD) in Children. Attention-Deficit / Hyperactivity Disorder (ADHD) in Children | Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/adhdadd. Published 2020. Accessed August 2, 2020.
  4. Attention-Deficit/Hyperactivity Disorder (ADHD): The Basics. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder-adhd-the-basics/index.shtml. Published 2016. Accessed August 1, 2020.
  5. Agency for Healthcare Research and Quality. Diagnosis of Attention-Deficit/Hyperactivity Disorder. Clinical Focus. Rockville, MD, October 1999. www.ahrq.gov/clinic/tp/adhddtp.htm.
  6. Albrecht B, Uebel-von Sandersleben H, Gevensleben H, Rothenberger A. Pathophysiology of ADHD and associated problems-starting points for NF interventions?. Front Hum Neurosci. 2015;9:359. Published 2015 Jun 24. doi:10.3389/fnhum.2015.00359
  7. Symptoms and Diagnosis of ADHD. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/adhd/diagnosis.html. Published April 8, 2020. Accessed August 2, 2020.